Joynt Maddox, Karen E

Objectives: Expanded coverage for telehealth during the COVID-19 pandemic allowed providers to bill for telemedicine services that were previously not reimbursable, including telemedicine critical care (TCC) services for critically ill patients. We aimed to characterize TCC billing practices among Medicare beneficiaries before, during, and after the COVID-19 pandemic. Design, Setting, and Patients: This was a serial cross-sectional study of adult Medicare Fee-For-Service beneficiaries with at least one bill for critical care at acute care hospitals from January 2018 to September 2024. TCC billing was identified using provider billing codes; multivariate regression models were used to determine characteristics associated with receipt of TCC. Key outcomes were patient-, provider-, and hospital-level characteristics associated with TCC billing. Interventions: None. Measurements and Main Results: Billing for TCC increased from 0.002% of critical care bills pre-pandemic to 0.01% of critical care bills during and after the pandemic. Patients billed for TCC were disproportionately likely to have COVID-19 but were otherwise relatively similar to critically ill patients not billed for TCC. Internal medicine/critical care providers accounted for the highest proportion of pandemic TCC bills (46.0%). TCC billing occurred more often at minor teaching hospitals (adjusted odds ratio [aOR], 1.21; 95% CI, 1.03–1.43) and at safety-net hospitals (aOR, 1.33; 95% CI, 1.04–1.70). TCC billing was less likely at small-sized hospitals (aOR, 0.39; 95% CI 0.26–0.58) and medium-sized hospitals (aOR, 0.67; 95% CI, 0.47–0.95), government-owned hospitals (aOR, 0.70; 95% CI, 0.57–0.86), for-profit hospitals (aOR, 0.58; 95% CI, 0.48–0.71), rural hospitals (aOR, 0.70; 95% CI, 0.55–0.89), and critical access hospitals (aOR, 0.59; 95% CI, 0.47–0.73). Conclusions: Billing for TCC among hospitalized critically ill Medicare beneficiaries increased during the pandemic but remained low as a proportion of all critical care bills. There was variability in utilization across subspecialties and lesser utilization at rural and critical access hospitals. Further studies are needed to characterize the clinical and economic consequences of this shift.

Background Despite its approval for acute ischemic stroke >25 years ago, intravenous thrombolysis (IVT) remains underused, with inequities by age, sex, race, ethnicity, and geography. Little is known about IVT rates by insurance status. Methods and Results We assessed temporal trends from 2002 to 2015 in IVT for acute ischemic stroke in the Nationwide Inpatient Sample using adjusted, survey ‐ weighted logistic regression. We calculated odds ratios for IVT for each category in 2002 to 2008 (period 1) and 2009 to 2015 (period 2). IVT use for acute ischemic stroke increased from 1.0% in 2002 to 6.8% in 2015 (adjusted annual relative ratio, 1.15). Individuals aged ≥85 years had the most pronounced increase during 2002 to 2015 (adjusted annual relative ratio, 1.18) but were less likely to receive IVT compared with 18‐ to 44‐year‐olds in period 1 (adjusted odds ratio [aOR], 0.23) and period 2 (aOR, 0.36). Women were less likely than men to receive IVT, but the disparity narrowed over time (period 1: aOR, 0.81; period 2: aOR, 0.94). Inequities in IVT resolved for Hispanic individuals in period 2 (aOR, 0.96) but not for Black individuals (period 2: aOR, 0.81). The disparity in IVT for Medicare patients, compared with privately insured patients, lessened over time (period 1: aOR, 0.59; period 2: aOR, 0.75). Patients treated in rural hospitals remained less likely to receive IVT than in urban hospitals; a more dramatic increase in urbanity widened the inequity (period 2, urban nonteaching versus rural: aOR, 2.58, period 2, urban teaching versus rural: aOR, 3.90). Conclusions IVT for acute ischemic stroke increased among adults. Despite some encouraging trends, the remaining disparities highlight the need for intensified efforts at addressing inequities.

Background: Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation. Methods: We used CDC WONDER (Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural versus urban residence, and degree of neighborhood segregation. Results: From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted cardiovascular mortality among Black (602.1 to 351.8 per 100 000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD, 155.1 [95% CI, 149.9–160.3]; 2019: ARD, 84.3 [95% CI, 81.2–87.4]). These patterns were similar for Black (824.1 to 526.3 per 100 000) and White men (637.5 to 396.0; 1999: ARD, 186.6 [95% CI, 178.6–194.6]; 2019: ARD, 130.3 [95% CI, 125.6–135.0]). Despite this progress, cardiovascular mortality in 2019 was higher for Black women (rate ratio, 1.32 [95% CI, 1.30–1.33])— especially in the younger (age <65 years) subgroup (rate ratio, 2.28 [95% CI, 2.23–2.32])—as well as for Black men (rate ratio, 1.33 [95% CI, 1.32–1.34]), compared with their respective White counterparts. There was regional variation in cardiovascular mortality patterns, and the Black-White gap differed across rural and urban areas. Cardiovascular mortality rates among Black women and men were consistently higher in communities with high levels of racial segregation compared with those with low to moderate levels. Conclusions: During the past 2 decades, age-adjusted cardiovascular mortality declined significantly for Black and White adults in the United States, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher cardiovascular mortality rates than their White counterparts.